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Extradural anterior temporal fossa approach to the paranasal sinuses, nasal cavities through the anterolateral and anteromedial triangles: Combined microscopic and endoscopic strategy

  • Original Article - Neurosurgical Anatomy
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To demonstrate the utility and limitations of the extradural endoscopic–assisted anterior temporal fossa approach to the pterygopalatine fossa (PPF), infratemporal fossa (ITF), paranasal sinuses (PS), parapharyngeal region (PPR), nasal cavities (NC), epipharynx (EP), and clivus.


A frontotemporal orbitozygomatic craniotomy is performed. The dura is elevated from the cavernous sinus (CS). The anterior temporal fossa floor is drilled. Foramen rotundum and ovale are opened. The PPF is exposed and the lateral margin of inferior orbital fissure (IOF) is removed. The anterolateral triangle (ALT) is drilled and the vidian nerve (VN) is exposed. Drilling between the maxillary nerve (V2) and the VN provides access to the sphenoid sinus (SphS). The medial pterygoid plate is drilled exposing the EP. The maxillary sinus (MaxS) is opened anterior to the PPF. V2 is transposed laterally to enlarge the anteriomedial triangle (AMT). The orbital muscle of Muller is removed as well as the medial margin of the IOF, which opens the SphS. Anteriorly, the posterior ethmoid air cells are opened. Morphometric measurements evaluating the size of the ALT were done and the PS, NC, EP were explored with the endoscope.


The ALT and AMT triangle provides a wide exposure of the PPF, ITF, PPR. In addition, those triangles represent a deep entry point to explore the PS, NC, and EP.


The ALT and AMT are useful corridors to access to the SphS, MaxS, PS, NC, and EP via a transcranial approach. The use of the endoscope through this corridor widely extend the extradural anterior temporal fossa approach which may be considered as a valuable alternative to the extended endoscopic endonasal approach for selected skull base lesions extending both intracranial and into the PS, NC and EP.

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We thank all the women and men who have donated their bodies for the advancement of scientific and surgical knowledge.

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Correspondence to Thibault Passeri.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the local Ethical Committee (Geneva Ethics Committee Board no. 11-233R, NAC 11-085R) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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The authors described in detail in this article the combined microscopic and endoscopic strategy they developed to reach the paranasal sinuses and the nasal cavities through an extradural anterior temporal fossa approach and subsequently the anterolateral and anteromedial triangles. The authors have to be congratulated for their work. They highlighted the way in which a microscopic anterior temporal fossa approach is modified into a more "extended" approach with the addition of an endoscope. This combined strategy owns several advantages to explore even through small corridors such as the antero-lateral and antero-medial triangles, the paranasal sinuses and the nasal cavities and turn around the corner to reveal blind spots.

The anatomical description, the quality of the dissection images and of the illustration are exceptional.

The 3 surgical cases nicely demonstrated the authors strategy and expertise.

A must-read article for anyone interested in skull base neurosurgery.

Michael Bruneau


This article is part of the Topical Collection on Neurosurgical Anatomy

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Watanabe, K., Passeri, T., Hanakita, S. et al. Extradural anterior temporal fossa approach to the paranasal sinuses, nasal cavities through the anterolateral and anteromedial triangles: Combined microscopic and endoscopic strategy. Acta Neurochir 163, 2165–2175 (2021).

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